June 2004

Watchful Waiting

By Michael J. Katin, MD

April showers bring May flowers and Mayflowers bring pilgrims but this year May brought two pertinent articles regarding diagnosis and treatment of prostate cancer. The May 4 issue of Annals of Internal Medicine included a discussion of the content of patient education materials about treatment of early-stage prostate cancer. This was limited to printed literature, web sites, videotapes, and CD-ROMs available at no charge from a variety of sources, ranging from patient advocacy groups to pharmaceutical companies. Amazingly, only 1/3 of the items were scored as describing risks and benefits of all four designated treatment options (watchful waiting, radical prostatectomy, radiation therapy, and hormone therapy). It is also amazing that an internet search indicated 300,000 web sites available on this topic, although the authors reviewed only the first 100; undoubtedly they missed some of the more interesting ones

The conclusion was that better materials for patient education should be available, for a variety of reasons, including needing quantitative conclusions about treatment results and the need to present material at a readable level (some were accused of being "text-dense"). In the real world, of course, most of our patients don't rely heavily on free literature but come in with books , with a retired physician who lives down their street, and occasionally with a cousin from Michigan whose brother-in-law was treated for prostate cancer three years ago and therefore is the family authority
on this disease.

It was somewhat disheartening to see that radiation therapy was listed third among treatments described in this literature review; granted this may not have been a conscious decision on their part, and at least we ranked above "hormone therapy," but we were behind both "watchful waiting" and "radical prostatectomy." We have nothing but respect for surgeons, but why should "watchful waiting" have been first?

The second article was from The New England Journal of Medicine and was picked up by the popular press. This paper noted that of 2,950 men (out of 18,882 enrolled in the Prostate Cancer Prevention Trial) who had a PSA level of 4.0 ng per milliter or lower and a normal digital rectal examination, and who then after 7 years on the trial had a prostate biopsy, 449 (15.2 per cent) had positive results, and of these, 67 had cancer with a Gleason score of 7 or higher. The conclusion was that even with a "normal" PSA level and unremarkable digital rectal examination that cancer could still be present. This was then followed by a question as to the relative value of early detection in terms of longevity.

This perhaps was part of the continuum from The New England Journal articles of September 12, 2002, regarding watchful waiting; one conclusion had been than radical prostatectomy reduced disease-specific mortality compared to watchful waiting, but there was not a significant difference in overall survival, at least in Sweden. Radiation therapy had not been an option, and only Swedes were studied.

Leaving aside the theoretical question of the results of radiation therapy on Swedes, it would be pertinent to realize that "watchful waiting" will always be with us. This was, of course, the first treatment ever avaiable for prostate cancer, having been used for over 10,000 years. The incidence of prostate cancer was very low until the 20th century, primarily due to the reluctance of medieval and Renaissance physicians to order PSA testing, let alone perform digital rectal
examinations.

Until the natural history of each individual's prostate cancer can better be predicted, watchful waiting could still remain a valid alternative to active treatment. The question is, what are we watching for? Is there too much of a risk of having the window of opportunity closed? Here is where the art of medicine comes in, as well as the expectation that at some point an unexpected event will stimulate a patient to reflect on life and make the final decision to go ahead with treatment or, less likely, stop getting checked.

Radiation oncologists should have an affinity for the concept of watchful waiting, since we're used to being watched and we're waiting all the time, anyway.

For example, suppose you're scheduled to see a new consult in the office at 4 p.m. You try to be on time but the records didn't come over yet from Dr. X, the referring physician; they'll be faxed over in 15 minutes. You check the patient's history sheets and half of them weren't filled out. These will be finished in another 20 minutes. In the meantime, you're asked to look over a treatment plan for someone who needs to start the next day. The computer hasn't been turned on but it'll be functioning and the plan can be uploaded within 8 minutes.
When you finally get to look at the plan, you realize you should go over it with the dosimetrist, who's currently on the phone with another office. You also remember that annual maintenance is coming up for that treatment unit, and you need to check with the physicist about the schedule, but she's just left to go to do coronary brachytherapy with your associate, who had been waiting the past 3 hours to be called for that procedure. You finally get to go over the plan and the physicist has called you back (19 minutes cumulatively). In the meantime, the patient has been put into a different room and you have to spend 2 minutes finding him. The nurse has now gone back to the lounge. One you've spent enough time talking to the patient, it's time for the physical examination. The ophthalmoscope hasn't been charged, and you have to get one from another room (1 minute). You get through most of the examination. Now you learn there's no lubricant in the room (1 minute, except another patient is in the other examination room and you have to speak with her before you can take the lubricant and leave--total 4 minutes). After the history and physical have been completed, you call Dr. X. He's at the hospital, and you have to wait for a call back, but that's all right, since you also have to call Dr. Y, who saw the patient two days ago for another problem. Unfortunately, she's on the telephone and has to call back. Both Drs. X and Y call back at the same time, resulting in the front desk losing both calls. After the patient leaves, you finally consummate the call with Dr. X. You need to get over to the hospital, but the therapists are running behind on treatments since one of the linear accelerators was showing a fault and they had to wait 30 minutes fo the engineer to check it out. You then have to wait until they finish before you can leave. That's all right, since you have the opportunity to dictate the consultation, except that halfway through you get called back by Dr. Y. You finally leave for the hospital and finish rounds, almost done with the patient except for the call you get through the answering service from his cousin in Michigan, who is the family authority on this disease.